Provider Demographics
NPI:1740264993
Name:SCOTT, MARILYN R (APN)
Entity type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:R
Last Name:SCOTT
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 BLACK COLE DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORT WASHAKIE
Mailing Address - State:WY
Mailing Address - Zip Code:82514
Mailing Address - Country:US
Mailing Address - Phone:377-335-5983
Mailing Address - Fax:
Practice Address - Street 1:28 BLACK COLE DRIVE
Practice Address - Street 2:
Practice Address - City:FORT WASHAKIE
Practice Address - State:WY
Practice Address - Zip Code:82514
Practice Address - Country:US
Practice Address - Phone:377-335-5983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209000504363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP38091Medicare UPIN